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Monday, August 24, 2009

Will Someone Rid Me of Private Health Insurance?

Michael Blim

So the Prez says we’re in a wee-wee period. Well, I am in a pee’d off period. Looks like nobody is going to rid me of my private health insurance. The public option looks dead.

I’m lucky. I have something I wish to be rid of. At least 46 million Americans don’t have anything -- not private insurance, Medicaid, or Medicare. According to experts quoted in the New York Times (8/23/09), another 25 million are badly under-insured.

I work for the City University of New York. My union along with other unions representing New York City employees has been able to negotiate decent health benefits. We have an array of plans we can join. All city agencies, including the university, contribute to the purchase of health insurance, $418 a month per person or $1025 a month per family, using the premium for a modestly priced plan with pretty modest benefits as its baseline. If you take the baseline plan, then it’s a wash. Your health insurance is free, though many costs fall outside the plan, and according to colleagues, it’s often tough to find a doctor who accepts patients with it.

So, for every employee, city agencies are paying either $5000 per person per year or $12,300 per family per year for health coverage. Every employee can choose more expensive insurance than the baseline policy, but the additional cost is on them.

I live in one state and work in another. I have access to treatment at a top-notch research hospital where I am domiciled. The insurance plan carried by the city that I have covers me in another state and includes most of my providers. Last year the plan cost me $306 over and above what the university paid for, which amounts to $3672 in premiums that were deducted from my pay.

The university contributes $800 annually to a union welfare fund that helps pay for our drug and dental expenses. I put in $50 a month to the welfare fund as well.

To summarize:The university contributes $5800 a year to cover my health, drug, and dental plans. I pay in $4300 a year. Together, we are paying $10,100 in total health insurance premiums. I’ve asked around. It could be a lot worse.

What do I get for $10,100? A lot of very good care. I do end up paying on average about another $2,500 a year for drugs and co-pays.

I also have extensive correspondence with the hospital, the insurance company, and the flunky medical management companies that the insurance company pays to certify my need for care for things like physical therapy, and to set the number of visits to which they believe I am entitled.

As of August 23, I have received and responded to 27 bills from the hospital this year. It’s about a co-pay they didn’t credit, or a mistake made by the new office assistant to the surgeon who did my shoulder repair in putting down the wrong codes for four office visits. Sometimes, the insurer throws the hospital a curve, rejecting claims that the hospital routinely expects to be paid without problem. I discovered, for instance, that certain services can demand a facilities fee, a kind of rent on the office where the provider ministers to the patient. It’s a bit like in the movies when the prostitute expects the John to pay for the room, except in the hospital, nobody tells the John.

A doctor can be smart as a whip, but he can be the kiss of death if he doesn’t know the codes. My family doctor is young, and gets so carried away actually talking with me in the course of the appointment that he screws up and forgets to mark the right code on the order sheet. Recently I got a big thumper of a bill for $600 for a shingles vaccine based upon a prior history of herpes zoster. My doc forgot to register it as medically indicated, and marked it preventative instead, which of course it was since I do not have shingles yet. That is why he ordered the vaccine, to prevent the shingles. God forbid that medicine prevents things, as far as my insurer is concerned.

Once a mistake is made and a bill made up, the paper chase begins in earnest. It is then that one uncovers the fact that unlike in the Wizard of Oz, there is no one behind the curtain. The hospital in a show of dauntless efficiency sends me one bill for everything they do to me. It is a complete sham. There is no unified billing service at the hospital. Every service simply dumps its bills into a big computerized hopper in the Ethernet, and a sum with unintelligible notations is derived and duly sent to the patient. I call to ask each service if it recorded a co-pay non-payment. Recently I made the rounds among the services billing for the podiatrist, the orthoticist, the physical therapist, the surgeon, and the family doctor. Sometimes it’s like bingo, and several of the services made claims for the “missing” $15 co-pay. Each service demanded documentation that I paid the co-pay, but even if one of the billing problems is resolved, the clearance never seems to stop the unified billing service from sending out another bill, this time with a dunning notice attached. One of the services refused to believe that I had not cheated them out of the $15 – this on a bill for a rotator cuff repair in which the hospital grossed thousands of dollars.

I told a fib when I said that there was no man behind the curtain. There are actually two: let’s call them Rafferty and Lafferty. Their office, I learned from one of the service’s customer representatives, is located miles from the hospital. They answer their own telephones (should you break the will of the customer service representative and get their number you can call them) and mete out summary justice like traffic court judges. On the first call, should you get lucky and they are in the office (the don’t return calls), they ask you to send documentation to an address that is not listed on the bills or the dunning notices. It’s a mail drop, a p.o. box with no address.

Then nothing much happens. I wait ten days; they don’t call; and I call again, hoping they answer. The second time they may remember the name, but the paperwork is never there, or it’s in process, meaning I suppose that it is in a pile somewhere. Then you begin to talk your way out of the hospital’s equivalent of the speeding ticket. Sincerity, good will, and an absence of attitude, and the mess goes away. These two gents, Rafferty and Lafferty, are two old-schoolers who are the judges and sole authorities of the court of last resort for clients being dunned by a multi-billion dollar hospital empire. They make an honest living helping people like me without expecting personal considerations that other courts from time to time are found to require. When they are on vacation, God help you.

But because of their tender mercies, 27 bills later as of this writing, I have a zero balance with the hospital. If only I could bill for those hours…

The insurer is much better organized, and it proves it by having sent me 37 missives over the course of the last 8 months.The insurer looks much more efficient, but don’t let the pleasant customer service representatives at the end of the phone tree fool you. They often end up just as much in the dark as do the folks at the hospital.

True they have a spiffy unified information system. All the bills, the debits, the credits, the co-pays – you name it, it’s all there. Unfortunately this means that all the errors the hospital made have now migrated onto their books, and the notations I get on the insurer’s statements are just as unfathomable to the customer service representatives as they are to me. This means that many things need to be researched or discussed with a supervisor. Sometimes one is told not to worry because the hospital will probably try to put the claim through again, which of course assumes that the hospital thinks it made a mistake and doesn’t decide simply to pass on the bill to me instead.

Other times, the insurer in its interest tries to rule my condition, my provider, my diagnosis, my treatment – which and whatever costs something – out of bounds, sort of like a bad forward pass, or having an ineligible receiver downfield, or, well pick whatever football metaphor works for you. The representatives send you back to re-educate the hospital in coding or to urge that the bill be re-submitted. This sometimes resolves thing shy of an appeal to the Rafferty and Lafferty.

However, the insurer has discovered over the years that a denial of treatment in the hand is better than two denials of payment in the future, with all of attendant paper work and appeals they will doubtless generate.

So they ration care. Rehabilitation for a rotator cuff repairs is limited to 6 visits, and another quota upon re-examination. This evaluation is undertaken by a company whose name has changed every year over the past three years, even though the phone number hasn’t. They are invested with the exlusive authority to decide how many visits it takes to rehabilitate my shoulder. Appeals can be made to their doctor on staff.

They did not stop the show this year as I rehabbed my shoulder, but they sure did slow it down. No appointments could be made without their permission; if they occurred before notification of the rehab department, I would have been liable. If they occurred after an imposed deadline, I would have been liable. And of course, the hospital, not missing any tricks, would pass on a bill puffed up 3 to 4 times more than the insurer would ever have paid them for the same service.

Alas unlike its parent, the orthopedic medical management outfit had no unified files, no unified anything from what I could determine. The rehab office would fax files, the therapist’s evaluations and the doctor’s prescription, and the faxes would be mislaid, and their arrival denied. Appointments would be cancelled, while I along with the therapist awaited word. Then I would call them, the hospital would call them, the fax machine would grind away again, and permission three weeks late would be granted. Over five months, they played stop and go quite effectively. They were like an Italian soccer team defending a one-goal lead: nothing too trivial, nothing too small was overlooked in keeping my “utilization” minimal.

This is what my $10,100 in private health insurance buys me. In just 8 months, 68 bills and letters and statements that needed explaining, fixing, and finally virtual appearances with two courts of appeal, the hospital and the insurer, both of whom wanted to kick the case onto the other court’s docket. It’s like hating both your spouse and your lover too. With the rotator cuff repair and a crown put on a 25-year old root canal tooth, I’m looking at up to $4000 in out of pocket expenses this year.

Both the hospital and the insurer have made a profit for the past half dozen years. Their CEOs make over a million a year. Despite the threat of general deflation, their prices will be going up next year.

So I say to friend and foe alike: who will rid me of my private health insurance?

And may I say to the assorted crazies around the nation:

You must like getting cheated. Medicare spends just 2% of its budgets on administrative expenses according to the Congressional Budget Office. Neither my hospital nor my insurer lists in any public place how much they spend on administrative expenses, or in the case of the hospital on billing and dunning, but is there anyone stupid enough to believe it is 2% or less of their gross? When the congressional accountability office (formerly the GAO) compared Medicare administrative expenses with the privately-run Medicare Advantage program (where the elderly can opt out of government Medicare and use a private insurer), expenses for the private programs ran 11% of their budgets and an additional 7% was devoted to profits. Instead of 98 cents on the dollar as provided for the elderly by Medicare, private Medicare recipients in 2006 received 83 cents on the dollar.

And those kindly folks who want to cut non-citizens out of national health care might want to consider that in our global world, pandemic diseases travel at the speed of a cough or an unwanted discharge. If non-citizens do not receive adequate medical care, or if America’s millions of poor desirous of medical care don’t get it, the diseases of the poor will become theirs. Note well: according to the Wall Street Journal (8/22/09), several million Americans now suffer from conditions new in such large numbers to the states such as Chagas disease, toxocariasis, cytomegalovirus (resulting in 8,000 babies born this year with birth defects including retardation), and cysticecosis. Success in combating these diseases and pandemics like swine flu and potential epidemics such as tuberculosis requires that people have regular access to medical care.

Unless, the Hitler-mustache painters would like to try sending 11 million non-citizens back to “where they came from,” which of course includes the 50 states, they might look on national health care as a kind of multi-dimensional, “homeowners” kind of insurance policy.

And finally, finally, what gives in this planet hysteria we call the states? Someone needs to tell the mad dogs, dumb dogs, and complacent dogs alike that the federal government already picks up 43% of the nation’s medical tab now. Never mind your invasion of the federal body snatcher nightmares, ninnies: that cow’s gone. Get real.

And we are better off for federal involvement. If you compare the health status of the elderly in 1965 with their health status today, dare I say one cannot fail to note that even after all the cheese whiz and sour cream and one potato chips, the elderly live better and longer, thanks to Medicare. And this, even after the Republican crazies over the course of 20 years tried to rip Medicare open at the seams.